Lumbar Spine Stenosis Algorithm

Definition: Clinical Syndrome of gradual onset of Intermittent buttock or lower extremity pain, with or
without back pain1,8. Symptoms are aggravated by standing or walking (neurogenic claudication3,6) and
relieved by sitting or leaning forward1,3,4,5,7,8. Spinal stenosis is associated with decreased space available
for neural elements (thecal sac and/or exiting nerve roots3) and epidural veins in the lumbar spine1,7,8.
The typical patient has a stooped forward posture, restricted lumbar extension, thigh pain with 30
seconds of lumbar extension.

Must differentiate from other conditions such as:

Peripheral Vascular Disease (Measure ankle brachial index)1,2,3,4,5,6,8
Diabetes1,4,6,8
Peripheral Neuropathy1,4,5,6,8
Hip/Knee Osteoarthritis1,5,6,8

Initial assessment of any back pain patient

Establish Standardized Score:

Ask patient to complete the Zurich Claudication Questionnaire9 and document score
Ask patient to complete the STarT Back Screening Tool (SBST) and document score

Assess your patient:

Conduct a focused history and physical examination

Review the standardized questionnaire scores

Classify your patient into one of five broach categories

Lumbar Spinal
Stenosis
Presence of Red Flags:

New Bowel/Bladder incontinence

or retention; recent sever trauma;
progressive paraparesis,
quadraparesis, neurologic sings
Send to emergency in your RUIS
(Rseau Universitaire Intgr de
Sant)
Unexplained weight loss (>10 lbs
over 6 months), fever, chills, saddle
anaesthesia without new
bowel/bladder incontinence or
retention; acute pain not eased by
recumbent position; incremental
non-relenting pain page spine
resident in the Emergency room of
your RUIS

Typical patient
> 50yr old1,3,4,5,8
Unsteadiness of
gait, weakness,
numb/clumsy
fingers go to
myelopathy
algorithm

Non-Specific
Low Back Pain
(NSLBP) Go
to
Acute/subacute
non-specific
low back pain
algorithm

Unilateral leg
pain below the
knee
(with/without
numbness and
weakness)
Go to
radiculopathy
algorithm

Educate:
Reassure patients development of cauda equina syndrome or severe progressive neurologic deficit rare3,4,5,6,7.
Advise patients to stay active
Promote self management
Discourage bed rest

Prescribe medication for paint relief (if needed):

Gabapentin4,10
NSAIDs1,3,6
Non-narcotic analgesics6
Narcotic analgesics (short course of maximum 2 weeks only if necessary)3,5

Prescribe Physiotherapy:
Strengthening of core muscles1,3,5,11
Stretching of lower extremity muscles (hamstrings, quadriceps, hip flexors)1,11
Lumbar flexion exercises (e.g. cycling)3,4,5,11
Avoid Lumbar extension exercises4,8

Elastic Lumbar binder (Wear only for brief periods to avoid deconditioning of para-spinal muscles)8

Follow-up visit (4-6 weeks after initial visit):

Purpose: keep the diagnosis under review and re-assess patients symptoms
Establish standardized scores again
Address any yellow flags or red flags

Improvement

Continue with same treatment

Re-assess regularly (every 6
months)

No improvement

Diagnostic Imaging:
MRI or CT myelograph (if MRI inconclusive or contraindicated)
CT scan (if MRI and CT myelograph are inconclusive, contraindicated or inappropriate)
Maintain intermittent communication with patient while awaiting imaging results

MRI reported as mildmoderate spinal canal or

neuroforaminal stenosis

Fluoroscopically guided
epidural injection (ESI)1,12,13,14
by:
Physiatrist
Pain management specialist

Follow-up in 3-4 weeks

MRI reported as severe spinal

canal or neuroforaminal
stenosis

Send the McGill Consult

referral Form to the McGill
Spine Program

MRI showed no evidence of

spinal canal or neuroforaminal
stenosis

Not a neurocompressive
disorder
Further work-up for
neuropathy/other pathology

Refer patient to Neurologist

for further assessment

Improvement

No-Improvement

Prescribe
Physiotherapy

Send the McGill

Consult referral
Form to the McGill
Spine Program

Follow-up in 3-4 weeks

Redevelopment of symptoms

Continued symptom resolution

2nd ESI (improvement with 1st) or

opioid analgesics

Continue with same treatment

Reassess regularly (every 6 months)

Follow-up in 4-6 weeks

Redevelopment of symptoms

Send the McGill Consult referral

Form to the McGill Spine Program

Continued symptom resolution

Continue with same treatment

Reassess regularly (every 6
months)

Maintain intermittent communication with patient while

awaiting consultant replies

Specialized Treatment (within the Spine Program)

Triage

Pre-visit Triage: Triager reviews patient consult and MRI/CT

Spine program initial visit: Keep diagnosis under review, looking for pathoanatomical causes related
to symptoms

Establish standardized score:

Ask patient to complete the spine program survey (Including the Zurich Claudication Questionnaire) and
compare to latest score from referring physicians office

Assess patient and make a decision

Tertiary care not required

Patient reassurance provided

Patient needs further nonoperative specialized,

multidisciplinary care

Patient is a surgical candidate

Psychologist

Request further imaging for

surgical planning:

Physiatrist
Physiotherapist
GP Sports Medicine

Standing AP and lateral

Scoliosis series
Flexion/Extension X-rays of
the Lumbar Spine

Surgeon decides on different

surgical options:
Decompressive Surgery
Lumbar fusion

References
1.
2.
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4.
5.
6.
7.
8.
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10.

11.
12.
13.
14.

Doorly TP, Lambing CL, Malanga GA, Maurer PM, Rashbaum RF. Algorithmic approach to the management of the patient with lumbar spinal stenosis. J
Fam Pract. 2010 Aug;59(8 Suppl Algorithmic):S1-8.
Manchikanti L, Helm S, Singh V, Benyamin RM, Datta S, Hayek SM, Fellows B, Boswell MV; ASIPP. An algorithmic approach for clinical management of
chronic spinal pain. Pain Physician. 2009 Jul-Aug;12(4):E225-64.
Issack PS, Cunningham ME, Pumberger M, Hughes AP, Cammisa FP Jr. Degenerative lumbar spinal stenosis: evaluation and management. J Am Acad
Orthop Surg. 2012 Aug;20(8):527-35.
Markman JD, Frazer ME, Girgis PS, McCormick KR. Diagnosis and Management Approaches to Lumbar Spinal Stenosis. J Current clinical care. 2011 Jan
Haig AJ, Tomkins CC. Diagnosis and management of lumbar spinal stenosis. JAMA. 2010 Jan 6;303(1):71-2.
Alexander JT. Lumbar Spinal Stenosis: Diagnosis and Treatment Options. Available from: http://www.dcmsonline.org/jaxmedicine/1999journals/june1999/lumbar.htm
Kreiner DS, Baisden J, Gilbert T, Shaffer WO, Summers J, Toton J, Hwang S, Mendel R, Reitman C. Diagnosis and Treatment of Degenerative Lumbar
Spinal Stenosis; Clinical Guidelines for Multidisciplinary Spine Care. North American Spine Society 2011
Yuan PS, Albert TJ. Managing degenerative lumbar spinal stenosis. The Journal of Musculoskeletal Medicine. 2009 June. Vol. 26 No. 6
Stucki G, Daltroy L, Liang MH, Lipson SJ, Fossel AH, Katz JN. Measurement properties of a self-administered outcome measure in lumbar spinal
stenosis. Spine (Phila Pa 1976). 1996 Apr 1;21(7):796-803.
Yaksi A, Ozgnenel L, Ozgnenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2007 Apr
20;32(9):939-42.
Goren A, Yildiz N, Topuz O, Findikoglu G, Ardic F. Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized
controlled trial. Clin Rehabil. 2010 Jul;24(7):623-31. Epub 2010 Jun 8.
Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998
Jun;14(2):148-51
Koc Z, Ozcakir S, Sivrioglu K, Gurbet A, Kucukoglu S. Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis. Spine
(Phila Pa 1976). 2009 May 1;34(10):985-9.
Cuckler JM, Bernini PA, Wiesel SW, Booth RE Jr, Rothman RH, Pickens GT. The use of epidural steroids in the treatment of lumbar radicular pain. A
prospective, randomized, double-blind study. J Bone Joint Surg Am. 1985 Jan;67(1):63-6.